Research and Evidence Base for EMDR
1. Introduction
Eye Movement Desensitisation and Reprocessing (EMDR) was originated and developed by Dr Francine Shapiro, who introduced EMDR to the professional and clinical world in 1989 with a randomised controlled trial of the method with a group of post-traumatic stress disorder (PTSD) sufferers (Shapiro 1989). Originally called EMD (Eye Movement Desensitisation), Shapiro renamed it EMDR emphasising the significant “Reprocessing” element in 1991, following developments in the method, and since 1995 EMDR therapy and procedures has remained in essence unchanged.
EMDR was originally designed to treat traumatic or “dysfunctional” memories and experiences and their psychological consequences. Although the procedure has increasingly been used to treat a wide range of experientially based disorders, e.g., anxiety, panic attacks, pain, performance problems, phobias, grief etc., it has primarily been used in the treatment of PTSD.
The evidence base for modern psychotherapies is usually assessed through what are known as randomised controlled trials (RCT’s). These are scientific and objective ways of comparing one treatment with another treatment, or with a wait list control, or by comparing the effectiveness of different elements of the psychotherapy. There were only six RCT’s across all psychological treatments for PTSD up until 1992 (Solomon et al, 1992). In contrast, since Shapiro (1989) published her seminal study on EMDR, there have been well over 100 case studies published on EMDR and at least 20 RCT’s just on EMDR and PTSD up until 2005. This amounts to significantly more research into EMDR than for any other single psychological or psychopharmacological approach to PTSD, and provides a strong basis on which evidence can be adjudged. The strong evidence base for the effectiveness of EMDR is reflected in the wide range of National and International guidelines endorsing EMDR as a treatment of choice for PTSD.
Outlined below are some of the most important research and guideline references related to EMDR.
2. National and International Guidelines
American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.
EMDR given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD.
Bleich, A. et al (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel.
EMDR is one of only three methods recommended for treatment of terror victims.
Chambless, D.L., et al (1998). Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.
According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported for the treatment of any post-tramatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy.
Crest (2003). The management of post traumatic stress disorder in adults. A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.
Of all the psychotherapies, EMDR and CVT were stated to be the treatments of choice.
Department of Veterans Affairs & Department of Defence (2004). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC
EMDR was one of four therapies recommended and given the highest level of evidence.
Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Health Care CBO/Trimbos Institute. Utrecht, Netherlands.
EMDR and CBT are both treatments of choice for PTSD, while the advantage of EMDR may be that it is tolerated better for the clients.
Foa et al (2000). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
In the Practice Guidelines of the ISTSS, EMDR was listed as an efficacious treatment for PTSD.
INSERM (2004). Psychotherapy. An evaluation of three approaches. French National Instittue of Health and Medical Research, Paris, France.
Of the different psychotherapies, EMDR and CBT were stated to be the treatments of choice for trauma victims.
Sjdblom, et al (2003). Regional treatment recommendation for anxiety disorders. Stockholm. Medical Program Committee/Stockholm City Council , Sweden.
Of all psychotherapies, CBT and EMDR are recommended as treatments of choice for PTSD.
United Kingdom Department of Health. National Institute of Clinical Excellence (NICE 2005). Post traumatic stress disorder (PTSD). The management of adults and children in primary and secondary care. London. NICE Guidelines.
Only EMDR and exposure recommended as evidence based psychological treatments for PTSD.
3. Meta-Analyses
Bradley, et al (2005). A multidimensional meta-analyses of psychotherapy for PTSD. American Journal of Psychiatry, 162, 215-227.
EMDR is equivalent to exposure and other cognitive behavioural treatments. It should be noted that exposure therapy uses one to two hours of daily homework and EMDR uses none.
Davidson, P & Parker, K (2001). Eye movement desensitisation and reprocessing (EMDR): A metal-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316.
EMDR is equivalent to exposure and other cognitive behavioural treatments but no evidence found for the utility of eye movements.
Maxfield, L & Hyer, L.A. (2002). The relationship between efficacy and methodology in studies, investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58, 23-41.
A comprehensive meta-analysis reported the more rigorous the study, the larger the effect.
Seidler, G & Wagner, F (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioural therapy in the treatment of PTSD . A meta-analytic study. Psychological Medicine, 36, 1515 – 1522.
EMDR and CBT equally efficacious.
Van Etten, M & Taylor, S (1998). Comparative efficacy of treatments for post-traumatic stress disorder. A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-144.
This meta-analysis determined that EMDR and behaviour therapy were superior to psychopharmaceuticals. EMDR was more efficient than behaviour therapy, with results obtained in one-third the time.
4. Randomised Controlled Trials (RCT’s)
Carlson et al (1998). Eye movement desensitisation and reprocessing (EMDR): Treatment for combat-related post-traumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.
Twelve sessions of EMDR eliminated post-traumatic stress disorder in 77% of the multiply traumatised combat veterans studies. Effects were maintained at follow-up. This is the only randomised study to provide a full course of treatment with combat veterans.
Chemtob et al (2002). Brief-treatment for elementary school children with disaster-related PTSD: A field study. Journal of Clinical Psychology, 58, 99-112.
EMDR was found to be an effective treatment for children with disaster-related PTSD who had not responded to another intervention. This is the first controlled study for disaster-related PTSD and the first controlled study examining the treatment of children with PTSD.
Edmond et al (1999). The effectiveness of MEDR with adult female survivors of childhood sexual abuse. Social Work Research, 23, 103-116.
EMDR treatment resulting in lower scores (fewer clinical symptoms) on all four of the outcome measures at the three-month follow-up, compared to those in the routine treatment condition. The EMDR group also improved on all standardised measures at 18 months follow up (Edmond & Rubin, 2004, Journal of Child Sexual Abuse).
Ironson et al (2002). Comparison of two treatments for traumatic stress: Acommunity-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, 113-128.
Both EMDR and prolonged exposure produced a significant reduction in PTSD and depression symptoms. Study found that 70% of EMDR participants achieved a good outcome in three active treatment sessions, compared to 29% of persons in the prolonged exposure condition. EMDR also had fewer dropouts.
Jaberghaderi, et al (2004). Acomparison of CBT and EMDR for sexually abused Iranian girls,. Clinical Psychology and Psychotherapy, 11, 358-368.
Both EMDR and CBT produced significant reduction in PTSD and behaviour problems. EMDR was significantly more efficient, using approximately half the number of sessions to achieve results.
Lee, et al (2002). Treatment of post-traumatic stress disorder. A comparison of stress inoculation training with prolonged exposure and eye movement desensitisation and reprocessing. Journal of Clinical Psychology, 58, 1071-1089.
Both EMDR and stress inoculation therapy plus prolonged exposure (SITPE) produced significant improvement with EMDR achieving greater improvement on PTSD intrusive symptoms. Participants in the EMDR condition showed greater gains at three month follow ups. EMDR required three hours of homework compared to 28 hours for SITPE.
Marcus et al (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy, 34, 307-315.
Funded by Kaiser Permanent. Results show that 100% of single-trauma stress disorder after six 50-minute sessions. Marcus et al (2004) Int. Journal of Stress Management, 11, 195-208 showed benefits maintained at six months.
Power, et al (2002). A controlled comparison of eye movement desensitisation and reprocessing versus exposure plus cognitive restructuring, versus wating list in the treatment of post traumatic stress disorder. Journal of Clinical Psychology and Psychotherapy, 9, 299-318.
Both EMDR and exposure therapy plus cognitive restructuring (with daily homework) produced significant improvement, but EMDR was 50% more efficient. EMDR was more beneficial for depression.
Rothbaum, B (1997). A controlled study of eye movement desensitisation and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, 61, 317-334.
Three 90 minute sessions of EMDR eliminated post-traumatic stress disorder in 90% of rape victims.
Rothbaum, et al (2005). Prolonged exposure versus eye movement desensitisation (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607-616.
In this NIMH funded study both treatments did equally well, although EMDR utilised no homework and less exposure time.
Scheck, M et al (1998). Brief psychological intervention with traumatised young women: The efficacy of eye movement desensitisation and reprocessing. Journal of Traumatic Stress, 11, 25-44.
Two sessions of EMDR reduced psychological distress scores in traumatised young women and brough scores within one standard deviation of the norm.
Shapiro, F (1989). Efficacy of the eye movement desensitisation procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199-223.
Seminal study appeared the same year as first controlled studies of CBT treatments. Three-month follow-up indicated substantial effects on distress and behavioural reports. Marred by lack of standardised measures and the originator serving as sole therapist.
Soberman, G.B et al (2002). A controlled study of eye movement desensitisation and reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment, and Trauma , 6, 217-236.
The addition of three sessions of EMDR resulted in large and significant reductions of memory-related distress, and problem behaviours by 2-month follow up.
Taylor, S, et al. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, 330-338.
The only randomised study to show exposure statistically superior to EMDR on two subscales (out of 10). This study used therapist assisted “in vivo” exposure, where the therapist takes the person to previously avoided areas, in addition to imaginal exposure and one hour of daily home @ 50 hours. The EMDR group used only standard sessions and no homework.
Vaughan, K et al (1994). A trial of eye movement desensitisation compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behaviour Therapy and Experimental Psychiatry, 25, 283-291.
All treatments led to significant decreases in PTSD symptoms for subjects in the treatment groups as compared to those on a waiting list, with a greater reduction in the EMDR group, particularly with respect to intrusive symptoms. In the 2-3 weeks of the study, 40-60 additional minutes of daily homework were part of the treatment in the other two conditions.
Van der Kolk, B et al (in press). A randomised clinical trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry.
EMDR was superior to both control conditions in the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve while the Fluoxetine participants again became symptomatic.
Wilson, S et al (1995). Eye movement desensitisation and reprocessing (EMDR): Treatment for psychologically traumatised individuals. Journal of Consulting and Clinical Psychology, 63, 928-937.
Three sessions of EMDR produced clinically significant change in traumatised civiliants on multiple measures. Wilson et al (1997). Journal of Consulting and Clinical Psychology, Volume 65, page 1047-1056, showed maintenance of treatment effects at 15 months.
A common suggestion is that EMs, or other dual attention stimulation elicit an orienting response facilitating the reprocessing of traumatic material. The orienting response is a natural response of interest and attention that occurs when attention is drawn to something new. There are three different models to explain the role of the orienting response in EMDR; cognitive/information processing (Andrade et al 1997, Lipke 1999), Neurobiological (Bergmann 2000, Stickgold 2002), and behavioural (Armstrong and Vaughan 1996, MacCulloch and Feldman 1996, Barrowcliff et al 2003). To some extent, these models view the same phenomenon from different perspectives.
Barrowcliff et al (2003) suggests that the orienting in EMDR is actually an “investigatory reflex”, that results in a basic relaxation response that occurs after realisation that there is no threat. By pairing this relaxation state with the previously upsetting memory, the client now has a new way of experiencing the memory and may notice a decrease in distress. This process is known as reciprocal inhibition.
Others suggest that the orienting response may disrupt the traumatic memory network, interrupting previous links to negative emotions, and allowing for the integration of new information. A study for Kuiken et al (2002), which tested the orienting response theory found that the eye movements were related to increased attentional flexibility. It is also possible that the episodic memories and integrate them into cortical semantic memory. This theory has recently received experimental support (Christman et al 2003). Further research is needed to test these hypotheses.
Brown, S and Shapiro, F (2006). EMDR in the treatment of borderline personality disorder. Clinical case studies, 5, 403-420.
De Jongh et al (1999). Treatment of Specific Phobias with Eye Movement Desensitisation and Reprocessing (EMDR); Protocol, Empirical Status, and Conceptual Issues.
De Jongh, A., Van den Oord, H.J.M., & Ten Broeke, E. (2002). Efficacy of Eye Movement Desensitisation and Reprocessing (EMDR) in the treatment of specific phobias: Four single-case studies on dental phobia. Journal of Clinical Psychology, 58, 1489-1503.
Grant and Threlfo (2002). EMDR in the Treatment of Chronic Pain.
Korn and Leeds (2002). Preliminary Evidence of Efficacy for EMDR Resource Development and Installation in the Stabilisation Phase of Treatment of Complex Posttraumatic Stress Disorder.
Lee et al (2006). The active ingredient in EMDR: Is it traditional exposure or dual focus of attention? Clinical Psychology and Psychotherapy, 13, 97-107.
Perkins, B. R & Rouanzoin, C.C. (2002). A critical evaluation of current views regarding EMDR. Clarifying points of confusion. Journal of Clinical Psychology, 58, 77-97.
Ricci et al. Some effects of EMDR on previous abused child molesters. Theoretical reviews and preliminary findings. (in press, Journal of Forensic Psychiatry and Psychology).
Rogers, S & Silver, S.M (2002). Is EMDR an exposure therapy? A review of trauma protocols. Journal of Clinical Psychology, 58, 43-59.
Servan-Schreiber, D et al (2006). Eye Movement Desensitization and Reprocessing for Posttraumatic Stress Disorder: a Pilot Blinded, Randomized Study of Stimulation Type. Psychotherapy & Psychosomatics, 75, 290-297.
Silver, S et al (2005). EMDR Therapy following the 9/11 Terrorist Attacks; A community based Intervention Project in New York City. International Journal of Stress Management, Volume 12, No. 1, 29-42.
Shapiro, F (2002). EMDR as an Integrative Psychotherapy Approach. American Psychological Association.
Spector, J. Eye Movement Desensitisation and Reprocessing (EMDR). In Press (2007). Chapter 6, Handbook of Evidence Based Psychotherapies: A guide for research and practice, Freeman, C and Power, M. Wiley.
Stickgold, R (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61-75.
Overall, EMDR appears to be an effective and particularly efficient therapeutic procedure for the treatment of civilian PTSD. As with all other current PTSD treatments, evidence for its utility in treating complex and multiple trauma is less convincing although when sufficient treatment time is given (in excess of the three sessions so commonly applied), eg., Marcus et al 1997, and Carlson et al 1998, the effectiveness of EMDR is impressive even with complex trauma.
Five out of seven direct comparisons of EMDR with exposure treatments for PTSD indicate superiority for EMDR, especially in terms of (speed of effects) efficiency (Rogers et al 1999, Ironson et al 2002, Lee et al 2002, Power et al 2002, Jaberghaderi et al 2004).
Developments in the theoretical basis of EMDR have become more interesting, cogent, and testable with a number of studies indicating specific effects of eye movements in reducing the vividness of emotionally imagery in traumatised persons.
It is clear that EMDR is an amalgam of different therapeutic elements of which eye movements or bilateral stimulation are just one element.